Prehospital Mortality Due to Hemorrhagic Shock Remains High and Unchanged: A Summary of Current Civilian EMS Practices and New Military Changes

Juan Duchesne, Sharven Taghavi, August Houghton, Mansoor Khan, Bruno Perreira, Bryan Cotton, Danielle Tatum, Megan Brenner, Paula Ferrada, Tal Horer, David Kauvar, Andrew Kirkpatrick, Carlos Ordonez, Artai Priouzram, Derek Roberts, Damage Control Resuscitation Committee

Shock 2020 Feb 19; Online ahead of print

Abstract

Mortality secondary to trauma related hemorrhagic shock has not improved for several decades. Underlying the stall in progress is the conundrum of effective pre-hospital interventions for hemorrhage control. As we know, neither pressing hard on the gas nor "Stay and play" have changed mortality over the last 20 years. For this reason, when dealing with effective changes that will improve severe hemorrhage mortality outcomes, there is a need for the creation of a hybrid pre-hospital model. Improvements in mortality outcomes for patients with severe hemorrhage based on evidence for common civilian prehospital procedures such as in-field intubation and immediate fluid resuscitation with crystalloid solution is weak at best. The use of tourniquets, once considered too risky to use, however, has risen dramatically in large part due success seen during their use in the military. Their use in the civilian setting shows promising results. Recently updated military Advanced Resuscitative Care (ARC) guidelines propose the use of prehospital whole blood transfusion as well as in-field use of Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Several case studies from Europe suggest these strategies are feasible for use in the civilian population, but could they be implemented in the U.S.?